Scenario: The Diabetic Patient and the Disappearing Insulin

Maria Rodriguez, a 62-year-old Hispanic woman, is a regular at the community health clinic. She manages her Type 2 diabetes through insulin injections. Maria lives in a cramped, multi-generational apartment with several family members, all struggling financially. She has no private space to store her medication. Over the past few months, the clinic staff has noticed a disturbing trend: Maria is consistently running out of insulin weeks before her refills are due. When questioned, Maria becomes evasive, muttering about high costs and “borrowing” from family.

The clinic uses an electronic health record (EHR) system which tracks prescriptions and refill history. The EHR flags Maria’s frequent early refills, raising a red flag for the attending nurse practitioner, Sarah. Sarah suspects that Maria’s insulin is being used by other family members, possibly for weight loss (a dangerous and unapproved practice), or sold on the black market to generate income. She is also aware that several family members struggle with obesity. However, she has no concrete proof. Confronting Maria directly has yielded no useful information. Sarah is torn. She needs to ensure Maria’s health, but doesn’t want to jeopardize the family’s already precarious financial situation or create further conflict within the household. She also has a responsibility to the clinic to ensure that prescribed medications are being used for their intended purpose.

Ethical Analysis

Care-Based Ethics: From a care-based perspective, the emphasis is on relationships and responsibilities. Sarah’s priority is to address Maria’s needs while maintaining trust and compassion. A care-based approach would involve:

• Building Trust: Sarah should engage Maria in a non-judgmental dialogue, focusing on understanding the underlying reasons for the missing insulin. This could involve home visits with community health workers who speak Spanish.
• Family Involvement: Sarah should attempt, with Maria’s permission, to involve other family members to understand the dynamic within the household and explore possible solutions.
• Community Resources: Sarah needs to connect Maria and her family with resources that can address the complex interplay of health, poverty, and family dynamics: diabetes education for the entire family, food banks, and perhaps social services for financial aid.

Rights-Based Ethics: A rights-based approach focuses on individual rights and duties. Sarah must consider Maria’s right to healthcare, her right to autonomy (to make decisions about her own body), and the rights of other family members. This could involve:

• Confidentiality: Maintaining Maria’s privacy is essential, but Sarah must also weigh this against her duty to protect Maria’s health, and the possibility of harm to other family members.
• Beneficence & Non-maleficence: Sarah must act in Maria’s best interest (beneficence) and avoid causing harm (non-maleficence). This is complicated by the potential misuse of insulin by others.
• Justice: Sarah needs to consider the fair allocation of limited resources, including the insulin itself, while understanding the structural inequalities affecting Maria’s family.

Assessment of Solutions:

Both approaches have limitations. Care-based ethics may be difficult to implement if Maria is unwilling or unable to share information. Rights-based ethics may be hampered by limited resources and the complex family dynamics. A combined approach, prioritizing building trust while exploring available resources, is likely the most effective, though imperfect, solution.

Healthcare Technology and Moral Guidelines

The EHR system is the key technology here. It serves a vital role in flagging potentially problematic patterns. However, it lacks contextual information.

Moral Guidelines for EHR Use (Utilitarianism): From a utilitarian perspective, the goal is to maximize overall well-being. The EHR data should be used to improve patient outcomes. This would mean that the possible use of the insulin for weight loss by other family members should not outweigh the importance of ensuring Maria has insulin. If this is the case, Sarah should report to the authorities to ensure the safety of Maria’s health. In terms of Maria’s health, this can involve reporting to the authorities that she might be in danger from her family.

Moral Guidelines for EHR Use (Kantian Deontology): Kant would argue that actions should be based on universal moral principles. In this context, it would mean that Sarah has a duty to be truthful and act justly. She has a duty to ensure that patients are being safe and healthy even if this means reporting to the authorities Maria’s situation.

Moral Guidelines for EHR Use (Ethical Egoism): An ethical egoist would prioritize their own self-interest. In this context, this may lead to neglecting the case entirely as this is the course of least resistance, especially when Maria refuses to elaborate on what is happening in her household. This would not be a viable course of action for a health care provider and if Sarah did so, her license would be in jeopardy.

Moral Guidelines for EHR Use (Social Contract Ethics): Social contract theory emphasizes agreements within society. Healthcare professionals have a social contract to care for patients. This should compel Sarah to ensure that Maria is receiving appropriate treatment and care by looking into what exactly is happening with Maria’s disappearing insulin.

Social Technologies

Blogs: Blogs could be used to raise awareness about the complex challenges faced by individuals managing chronic conditions in poverty, like the situation Maria faces. Patient advocacy groups can describe their experiences, generating empathy and pushing for systemic changes.

Crowdfunding: Crowdfunding might be used to help patients like Maria access medications or devices they cannot afford. However, strict guidelines are required to ensure transparency and prevent misuse. In Maria’s case, it might not be the best solution because she is unwilling to reveal how the family uses the insulin she is given.